Oxbryta — Medical Mutual

Initial criteria

• Patient is age ≥ 4 years
• Patient has a history of at least one vaso-occlusive crisis (VOC) in the prior 6 months
• Patient has tried and failed hydroxyurea and L-glutamine

Reauthorization criteria

• Patient is age ≥ 4 years
• Patient has had an appropriate hemoglobin response to use of Oxbryta, as determined by the prescriber

Approval duration

1 year initial, 1 year reauth